tion, foul breath, and continuous chronic pharyngitis; (5) enlargement sufficient to impair speech, respiration or deglutition; (6) small submerged tonsils, the structure of which is often one suppurating mass, with which subtonsillar disease is associated.

The author does not favor the use of the guillotine on any patient over seventeen years of age, or in submerged tonsils. It is wiser to remove the whole tonsil, an operation more easily accomplished by the use of the cold snare, it being both safe and thorough, providing it be not too fine. As there is danger of homorrhage, crushing the tonsil is preferable to cutting it. The Dundas-Grant tonsil punch is particularly useful in removing the small hard tonsils of adults and the long flat tonsils when it is difficult to get sufficient of their substance into the guillotine. In order to avoid hemorrhage care should be taken with the dressings. All exertions should be avoided. Any tendency to clear the throat should be guarded against and the eschar which forms should be allowed to come away itself.

The writer holds that operations should be refused in cases of hemophilia.

OPHTHALMOLOGY.

BY WALTER ROBERT PARKER, B. S., M. D., DETROIT, MICHIGAN.

CLINICAL ASSISTANT IN OPHTHALMOLOGY IN THE DETROIT COLLEGE OF MEDICINE.

THE USE OF THE X-RAYS IN OPHTHALMIC SURGERY. MAYOU, M. S., London (The Lancet, February, 1903), after reviewing the uses of the x-rays in localization of foreign bodies in the globe and rodent ulcers, gives the following report:

"In the x-rays we have a method of setting up a leucocytosis with the absolute minimum of destruction to epithelial and other tissues; and further we have a means of producing inflammation from a very slight leucocytosis to an actual gangrene of the part which with due care and experience we have under almost perfect control. Not knowing the organism which causes trachoma we cannot say whether the irritants which are used in its treatment, or the r-rays, have any effect on it. But we have in the r-rays a method of producing leucocytosis in any degree of severity from that following a mild application of perchlorid of mercury up to that induced by jequirity; and, further, this leucocytosis is much more prolonged than that in any method previously adopted and the destruction is not nearly so great. Although granules disappear very rapidly under the x-rays, operative methods, which have the additional advantage of removing the diseased tissue, must be preferable to some extent except that the patient has to undergo an operation, but such operations can be followed by the x-rays to complete the work in preference to one of the other irritants now in use. Operation, however, should never follow x-ray treatment without considerable interval.

"At the beginning of 1902 I showed before the Ophthalmologic

Society a case of trachoma which had been treated by the x-rays and which, so far as I know, was the first of its kind. The method adopted was to recover the whole face, with the exception of the effected eye, with a metal mask. (Since then I have discarded the mask altogether and now I never expose the patient sufficiently to get any reaction at all in the skin.) The upper lid was then everted and the lower lid was pushed up so as to cover as much of the cornea as possible, but in bad cases of pannus the cornea is exposed. I never have had any trouble with the globe following r-ray treatment, and in a case of rodent ulcer of the lid in which the treatment was used for six months and which I showed at the same society last June there were no signs of retinal, corneal, or other affection, with the exception of conjunctivitis, and the patient's vision remained the same (6/9) throughout the treatment. The patient is seated about nine inches from the anode with a moderately soft tube and a current of six amperes. Two minutes exposure is given for from four to six successive days, depending on the case. If there be much injection or the case be an acute one, four are generally sufficient. A week's rest is then given and if no reaction is set up the patient is exposed twice a week until there is a slight increase in the photophobia, which shows that he is beginning to react. About this time the granules begin to disappear from the lids. Exposures once, twice or three times a week are carried out until they disappear entirely. When once the granules have disappeared all treatment must be stopped, as it requires some weeks for the infiltration set up by the x-rays to settle down and it is difficult to tell whether the disease is absolutely eradicated, as the lids remain injected for some time after treatment has ceased. The final result to the lid is most satisfactory. Instead of the white, puckered conjunctiva gained by other methods a supple, noncontracted, nonscarred conjunctiva, with no obliteration of the fornices, unless they are already gone before treatment, is produced, similar to the soft, supple scar in the skin following this form of treatment in rodent ulcer, as compared with the dense cicatrix of excision.

"As regards the effect on pannus, it often clears with great rapidity, especially if recent, and it is the common thing for patients to say that they see more clearly from almost the first exposure. But even the dense corneal opacity will often clear considerably and in one case of extensive destruction and cicatrization of the cornea, in which at the commencement of treatment the patient could only see shadows, in two months she could count fingers three feet away. Another peculiar point is the amount of exposure required by different patients. Sometimes the granules begin to disappear from almost the first exposure; others require from eight to ten exposures before showing signs of reaction.

"With regard to cases suitable for treatment, the most satisfactory are the chronic cases, and of course the earlier they seek treatment the more rapid and satisfactory is the result. These patients will stand more frequent exposure than others; acute diffuse infiltrations with thickening of the lids and much photophobia require more careful

exposures and extending over a much longer period. Old standing cases in which the lid trouble has almost disappeared, but in which there is much opacity of the cornea, will often improve under exposure of long intervals after the first reaction, which should be mild. The chief advantages of this treatment are: (1) There is considerably less deformity in the lid after treatment; (2) it is practicly painless treatment; and, (3) pannus clears more thoroughly. It is eminently suitable for hospital patients who cannot attend daily for other methods of treatment to be carried out. In the first cases the patients were troubled with some falling out of iashes and conjunctivitis. In no other case out of some fifteen has there been similar trouble."

LARYNGOLOGY.

BY WILLIS SIDNEY ANDERSON, M. D., DETROIT, MICHIGAN.

ASSISTANT TO THE CHAIR OF LARYNGOLOGY IN THE DETROIT COLLEGE OF MEDICINE

CHRONIC SPHENOID ABSCESS.

LEWIS S. SOMERS (American Medicine, February 28, 1903) gives briefly the anatomy of the sinus and its relation to the important structures adjoining it. He outlines the principal symptoms of empyema of the sinus, such as pus in the nasal passages, pain, ophthalmic symptoms, meningitis, thrombosis and suppuration of the cavernous sinus. The detailed history of a case is given, which illustrates the symptoms. outlined. He calls attention to the three methods of entering the sinus, (a) the natural intranasal route; (b) through the frontal sinus; (c) by way of the maxillary sinus. The intranasal route is the one described. Irrigation with weak antiseptic or normal saline is advised, and the interior of the sinus is treated as indicated, either with a weak trichloracetic acid or zinc chlorid solution. If the mucosa of the upper and external wall is diseased it is treated with the solutions mentioned, while the other portions of the sinus are curetted gently as no risk with careful handling is involved here. The curetting of the anterior wall and floor often produces beneficial results without further treatment. Necrosed bone is removed so far as safety will permit, and as the necrosed area is usually on the anterior wall it can be removed with perfect safety. The sinus is then irrigated and may be packed with iodoform gauze, although the author prefers drainage without gauze.

THE ANATOMY OF THE SPHENOIDAL SINUS AND THE METHOD OF APPROACHING IT FROM THE ANTRUM.

HARRIS P. MOSHER (Laryngoscope, March, 1903), in an exhaustive article with a formidable bibliography, gives in detail the anatomy, development and relations of the sinus, and discusses methods of entering the sinus. The nature of the article is such that it cannot be easily abstracted.

TRANSILLUMINATION OF THE NASAL ACCESSORY SINUSES DURING ACUTE CORYZA.

CAROLUS M. COBB (Journal of the American Medical Association, February 28, 1903) states as a summary:

(1) That to do satisfactory work it is necessary to have lamps of much greater candle power than those usually sold by instrument dealers.

(2) That it is rare to find the accessory sinuses dark on transillumination during the early stages of acute coryza.

(3) That during the later stages of a prolonged attack it is the usual result to find one or more of them dark.

ease.

(4) That hemicrania is often closely associated with antrum dis

(5) That it is almost the rule to find one or more of the nasal accessory sinuses involved when the ears are affected during acute

coryza.

EMPYEMA OF THE ACCESSORY SINUSES OF THE NOSE.

J. H. WOODWARD, New York (Medical News, February 21, 1903), gives first the anatomy and relations of the various sinuses of the nose. Inflammation of the accessory sinuses may be either primary of secondary, acute or chronic. The most universal subjective symptom observed in pyogenic inflammation in these regions is pain. In maxillary sinusitis the pain is usually located 'beneath the orbit; in ethmoid disease it is in the frontal region and behind the eyeball; in sphenoidal sinusitis it is deeply seated behind the eyeball, or in the vertex, or in the occiput. There are variations from these rules. Tenderness. on pressure over the affected sinus is usually present. The objective symptoms are those of a more or less intense rhinitis and a purulent discharge from the nose, which varies much in amount. Edema of the cheek and about the eye and forehead, and inflammatory swellings in those regions are observed in certain cases of antral and frontal sinus suppurations. Conjunctivitis, photophobia, exophthalmos, phlegmon of the orbit, optic neuritis, meningitis and cerebral abscess have all been observed as complications of sinus disease. The natural course of acute inflammation of the accessory sinuses is toward complete and permanent recovery. Chronic sinusitis, on the other hand, runs a protracted course without manifesting any tendency toward spontaneous

cure.

The treatment outlined consists in combating the disease upon which they depend. Relieve congestion and obstruction in the nose in order to restore the patulency to the natural openings of the sinuses. In more chronic cases such operative measures should be taken as are necessary to give drainage and the cavity treated on general surgical principles.

[The above abstracts of a few of the many articles published during the past season show the increase of our knowledge of sinus affections. The diagnosis of some of the obscure cases is very difficult,

and requires a most careful examination and exclusion of other diseases. Many cases are not recognized during life. The death, supposed to be due to brain disease, is shown by the autopsy to be primarily of sinus origin. Many of these cases fall into the hands of the family physician, so it is important that the general practician have in mind. the possibility of sinus disease and remember a few of the symptoms diagnostic of the affection. The following is a summary of a few important diagnostic symptoms of sinus disease: Pain is very important. It may be most noticeable in the frontal or orbital regions, or in cases of sphenoidal disease of a deep boring nature as if situated in the center of the head. Tenderness may be present at the root of the nose, or the inner canthus. A purulent discharge, constant or intermittent, is very characteristic. Nasal obstruction on the affected side is usually present. Irregular fever, insomnia and nervous symptoms develop in severe cases. w. s. A.]

PSYCHIATRY.

BY WILLIAM MILAN EDWARDS, M. D., KALAMAZOO, MICHIGAN.

MEDICAL SUPERINTENDENT OF THE MICHIGAN ASYLUM FOR THE INSANE.

INSANITY IN IMBECILES.

DOCTOR A. F. TREDGOLD (Journal of Mental Science, January, 1903) writes fully on the subject of insanity in imbeciles and gives abstracts of illustrative cases. He says insanity is rarely met with in the more pronounced grades of amentia but is comparatively frequent in the higher grade imbeciles. But scant attention has been given to this subject in the literature. He gives some description of the general characteristics of the high grade imbecile but does not enter into a full discussion of these cases. He says that one of the commonest statements is that they have not learned at school, particularly he finds that arithmetic is a great stumbling block and they have not passed the third, second or often the first grade. Such persons learn to walk and talk late and dentition and development are retarded. He states that the cases of insanity in imbeciles that he has seen have been in those of high or medium grade, but it by no means follows that all high-grade imbeciles are liable to be so afflicted. Those who become insane have nearly always for some years before the actual outbreak been prone to strong fits of irritability, moroseness, sulkiness or acts of violence or have wandered away from home and caused much trouble by restless disposition.

The author divides the high grade imbeciles into two groups, the mentally stable and the mentally unstable; insanity occurring among the latter class, and he considers this instability the most important factor in its production, exciting causes playing a minor part. In a mentally unstable imbecile the chances of his passing through the third decade without becoming insane are very small indeed. Institutional life of the right kind, begun sufficiently early, would probably do much to prevent insanity in such persons. In the mentally unstable imbeciles